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David McGill Blogger

2014's New and Modified Codes - What You Need to Know

Posted by David McGill | December 09, 2013

Medicare has released the 2014 HCPCS codes. Here's what you need to know.

1. Orthotics

Medicare has modified the language of 23 already-existing L-codes to add the words, "prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise" to the end of the description. Simultaneously, it has created 23 new codes that have exactly the same descriptors as the 23 referenced in the previous sentence except for the fact that the quoted language above has been replaced by the words, "prefabricated, off the shelf."

In addition, Medicare has modified the language of several other L codes to include the "trimmed, bent, molded, assembled" language quoted in the previous paragraph.

What does this mean for you?

The creation of 23 new code "pairs" differentiated only by whether the device is "off the shelf" or "customized to fit a specific patient by an individual with expertise" may be the most significant change ever in the world of orthotic coding. We see 3 potential key ramifications.

First, Medicare gets to now set (lower) fees for the 23 new OTS codes. This could have a profoundly negative financial impact on suppliers of these devices depending on how much lower Medicare prices the OTS codes than their custom-fit counterparts. The fee schedule for these new OTS codes could be effective on January 1, 2013, but we will need to await the release of the 2014 HCPCS Fee Schedule to learn whether that's the case.

Second, we can expect the Recovery Auditors and MACs to increasingly focus on the sufficiency of suppliers' documentation, especially for devices described by these new "custom-fit" codes. Suppliers' records will now have to contain solid evidence that     "trimming, bending, molding, assembling, or otherwise customizing" the device occurred. 

Third, by requiring "an individual with expertise" to fit the patient,  Medicare may be trying to discourage entities and individuals who lack the requisite experience and training from delivering and billing orthotics under the "custom-fit" codes. While this might actually help limit fraud and abuse perpetrated on the Medicare system by unqualified individuals, it remains to be seen what the words "an individual with expertise" actually mean.

2. Prosthetics

Medicare created one new L code for prosthetics describing an ankle-foot system with "power assist." The actual fee associated with this code could be included either in the January 1, 2014 fee schedule update or the July 2014 update. We will have the answer to that question in the next few weeks when Medicare does post the 2014 fee schedule.

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We will keep you posted regarding future coding developments as that information becomes available in the coming weeks. 
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